Inspection on 06/11/06 for Alison House

This inspection was carried out on 6th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alison House 18/02/09

Alison House 01/03/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Alison House 7 Newton Street Basford Stoke on Trent ST4 6JN Lead Inspector Sue Jordan Key Unannounced Inspection 6 November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alison House Address 7 Newton Street Basford Stoke on Trent ST4 6JN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 4513746 0121 4513746 Mrs Shanti Odedra Mr Sunil Odedra Mrs Catherine Mary Redman Care Home 30 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (24) Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20/02/06 Brief Description of the Service: Alison House is situated in the Basford area of Newcastle Under Lyme. Alison House is registered as a residential care home for 30 older people. They are also registered to provide care to 6 people with dementia care needs and 6 with mental disorder. At the time of the inspection there were 20 people residing in the home. The management have recently submitted an application to the Commission for Social Care Inspection to increase the numbers of people with dementia care needs they can support. Alison House has had a new owner and acting manager since the last inspection. The acting manager is preparing to register with the Commission for Social Care Inspection. The new owner and manager recognise that the environment requires refurbishment and work has started on re-decoration. The home is on 2 levels and single bedrooms are available on both floors. Some of the bedrooms have en-suite facilities. There are a variety of communal spaces in the home: a large conservatory looking over a paved courtyard area at the back of the home and two lounges at the front. There is a separate dining room adjacent to the kitchen. The home provides home cooked meals, with a varied menu. The fees charged range from £304-£334 per week. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and three-quarter hours. The methodologies used were scrutiny of pre-inspection information completed by the manager and sixteen Commission for Social Care Inspection comments cards; seven completed by relatives and nine by residents. On the day of the inspection one resident was spoken to at depth and a relative gave her views of the home. Three members of staff were interviewed and discussions were held with the acting manager, the deputy manager and the new owner. The records for one new member of staff employed since the last inspection were checked. Two residents’ care records were checked, including those of the most recent admission to the home. A random selection of the Health and Safety records were seen and a tour of the environment was undertaken. Observation of non personal care practices was made, including interaction between the staff and residents, activities and the administration of medication. What the service does well: The acting manager ensures that appropriate assessments are undertaken of any prospective resident. This includes assessments by social workers for referrals by the Local Authority and assessments by the management team. Health care needs are monitored closely. All relevant information is recorded in the care records. The medication systems used in the Home are good. Visitors are made welcome and the residents praise the quality of the food provided. The acting manager keeps the Commission for Social Care Inspection informed of any significant events or changes in the Home. Daily activities are organised and there are plans to increase and improve these for people with dementia care needs. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 6 The residents are able to make choices within their daily lives. They are able to rise and go to bed when they wish and there is a varied menu. A choice of activities is provided throughout the day or there are sufficient spaces in the home to be quiet or have privacy. 50 of the staff team have achieved National Vocational Qualification 2 in care or above. What has improved since the last inspection? The care plan formats are in the process of being changed. These allow for more comprehensive recording of residents’ needs and the support required by staff. Daily records are now being completed for every shift and the new system will also provide more evidence of monthly reviews. Improvements have been made to the environment. The new owner and manager have identified the changes required and to date four bedrooms have been re-decorated. The home has been de-cluttered and a maintenance person employed. Furniture has been re-arranged in the conservatory giving it a more homely and cosy feel. The acting manager has reviewed staff responsibilities and delegated duties. The staff spoke positively of the changes. The manager is keen to improve the activities provided for people with dementia care needs. She has introduced a key worker system and as part of this 1:1 activities are being organised. A more relaxed atmosphere was noticed within the home. This has also been noticed by one of the district nurses. Recruitment procedures have improved. The appropriate checks are being made for prospective employees. An induction programme is in place for the most recent recruit. A Quality Assurance system has been introduced, which includes gathering the views of residents, relatives, staff and visiting professionals. The new owners use an independent body to audit the home on a monthly basis. Copies of their reports are sent to the owner, manager and the Commission for Social Care Inspection. Staff are being formally supervised, although some suggestions were made for improvement. A new seasonal menu has been designed. This rotates on a 4 weekly basis. The residents were asked to make requests and suggestions. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 7 Staff have attended a range of training courses in the last few months, including fire safety, Health and Safety, Protection of Vulnerable Adults, dementia, Emergency First Aid and The Safe Handling of Medicines. The records have been re-organised and are now maintained in an efficient and accessible manner. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed before they are offered a place in the Home, ensuring that their needs can be met. EVIDENCE: The Home’s Statement of Purpose has been updated to reflect the change of ownership and management of Alison House. It was identified that some residents and relatives are not aware of the complaints procedure. The acting manager gave a copy of the Statement of Purpose and Service Users Guide to the most recent resident. She is going to make sure that all residents and their relatives have a copy. The care records of the most recent admission into the Home were checked. The acting manager had obtained a Local Authority assessment and care plan prior to admission. The management also visited the service user in hospital to Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 11 undertake an ‘in-house’ assessment. Information from the assessment has been transferred into a care plan format. The care plans are in process of being improved. Alison House does not provide intermediate care. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Major improvements are being made to care planning and the residents’ records. When fully implemented the new system will ensure that the staff have the information required to meet the residents’ needs. EVIDENCE: The care records for two residents were checked. Work has commenced to implement new care plan formats. One of the files seen contained the new paperwork and major improvements were noted. The new formats allow for more detailed information as to how service users’ needs are to be met. Daily records are now being completed for every shift and a key worker system has been introduced. The new system will also provide more evidence of monthly reviews. One of the staff is trained to train manual handling. She has undertaken mobility assessments for each of the residents. It was recommended that they Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 13 be expanded to include more information as to how the residents are to be supported. The care records provide evidence of access to appropriate health professionals for example, general practitioners, district nurses, chiropody and opticians. A district nurse completed a Quality Assurance questionnaire and commented that: “May I say since a change of ownership the care and general improvement of the surroundings has been noticeable and both staff and residents seem happier and relaxed”. Administration of the lunch-time medication was observed. This was carried out in a satisfactory and sensitive manner. Recording is robust. A pharmacist comes to Alison House twice a year to carry out an audit of the medication procedures. The management team and senior care workers administer medication and they are all completing the ‘Safe Handling of Medicines’ training. The deputy manager is responsible for stock rotation and ordering new medication. The manager reported that consideration is being given to a monitored dosage system. The staff were seen interacting in a positive and respectful manner with the residents. One of the residents said that the care workers helped her to move around the home and with her personal care. She said that she did not have to wait and that they came to her as soon as they were asked. All of the residents have their own bedrooms and they are fitted with a lock. Some of the residents are able to use a key, whilst others choose not to or are not able to. The manager was reminded that she should justify this within the care records, probably within a risk assessment. The home has sufficient space to enable the residents to have privacy if they wish. The furniture in the conservatory has been re-arranged into smaller, more cosy seating areas, which were being used by residents and their visitors. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are encouraged to make choices throughout their daily lives and a variety of activities are provided. This will be further enhanced by the manager’s proposed plan to increase the range of activities for people with dementia care needs. EVIDENCE: The residents are able to get up and retire when they wish and this was confirmed in discussions with them. Breakfast is served any time between 08:00 and 10:00. It was reported that most residents stay in bed until 08:00. The exceptions to this get up earlier out of choice and do so independently. The manager reported that most of the residents like to stay up until the night staff come on duty at 22:30. There is facility to record the residents’ preferred daily routines within the new care plan format. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 15 Activities are organised daily. On the morning of the inspection, some of the residents were playing a game of bingo, whilst others were listening to music. During the afternoon some residents played ‘hangman’, whilst others sang along to music from their youth. One of the residents said that she loved getting involved in the activities and that they also included skittles, ball games and exercises to music. The manager is keen to organise more activities for the residents with dementia care needs. She has introduced a key worker system and a member of staff interviewed confirmed that part of this responsibility is to organise 1:1 activities. Activity tables have been placed in the conservatory for this purpose. One of the staff said that she had spent time looking at photographs with one of the residents. There is facility to record any participation in activities within the new care plan formats. One of the residents goes to church every Sunday with a friend; plans are being made for another to be taken. The local Church of England vicar visits Alison House once a month to offer the residents communion. A resident with dementia care needs is taken to Stoke every week. This was assessed as being very important to the resident and agreement was made with the family. Initially it was agreed that the manager would accompany her to assess the safety of the visit. The manager will complete a risk assessment before allowing staff to undertake this duty. A number of relatives were seen visiting Alison House during this inspection. A discussion was had with one of the relatives who said that she visited every day and was made welcome by the staff. She said that she was pleased that they had chosen Alison House. Seven questionnaires were completed by relatives and sent to the Commission for Social Care Inspection prior to this visit. All were positive regarding the care provided at Alison House. One said: “The staff at Alison House are always welcoming and cheerful and very helpful”. New seasonal menus have been introduced and the views of the residents have been sought. This was confirmed by one of the residents, who said that she had asked for liver and onions, which is now being provided. One of the residents said, “We wouldn’t get better food if we were in a high quality hotel.” Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 16 Lunch is a three-course meal, with soup provided daily. The tables are nicely set and the residents can choose to sit alone or in a group. Vegetables are provided for every table in serving dishes and gravy within a gravy boat. There is a choice of sandwiches or a light cooked meal for tea. The cook works from 08:00-17:00. A number of residents were asked if they had enjoyed their lunch and they were all enthusiastic in their response. A relative visiting during this inspection said that her mother always said that she enjoyed the food and that she ate really well. Discussions with the cook indicated that fresh vegetables, milk and fruit are provided. All meals are home-cooked, including home baking. Three of the residents are provided with a diabetic diet. Drinks were provided at regular intervals during the day and when required fluid balance charts are completed. The residents are offered a choice of drinks, although it was noticed that fresh fruit juice is not available. The manager said that it had been available previously but not popular. She said that she would re-introduce it to the menu. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although a more open culture is being encouraged, the manager needs to ensure that all relevant parties are aware of the complaints procedure. The residents are protected by robust recruitment and staffs’ training and awareness of Protection of Vulnerable Adults procedures. EVIDENCE: There has been one complaint made to the previous manager/owner since the last inspection. This was addressed immediately. Ten questionnaires were completed by residents and sent to the Commission for Social Care Inspection. Most said that they knew who to speak to if they were unhappy or wanted to make a complaint. However, there were some who did not appear to be as sure, saying that they ‘sometimes’ or ‘usually’ knew who to complain to. Of the seven questionnaires completed by relatives, three said that they were not aware of the complaints procedure, although all said that they had not made a complaint. The acting manager has however implemented a Quality Assurance system, which has included the sending of satisfaction questionnaires to residents, relatives and professionals. She is also planning to hold some residents’ meetings. She demonstrates a determination to create a more open culture in Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 18 the home, by encouraging more involvement and input from staff and residents. This includes the introduction of a staff supervision system, regular team meetings, newly delegated responsibilities and plans to hold residents meetings. The staff spoken to said they found the new manager and owner approachable and felt able to raise with them any concerns they may have. The manager needs to make sure that the complaints procedure is freely available to all relevant parties. This issue could be discussed at residents’ meetings. The possibility of an introduction letter was discussed with the manager. Loose-leaf sheets are presently used for recording complaints. The manager was advised that a hardback book should be used. It is also recommended that all concerns and grumbles be logged as evidence that action is taken to address all issues, no matter how ‘minor’. Discussions with staff indicated an awareness of the Protection of Vulnerable Adults and Whistle Blowing procedures. They have recently received training in this area. Staff recruitment procedures have greatly improved. Protection of Vulnerable Adults and Criminal Records Bureau checks are being carried out for all prospective employees. The residents’ families manage their finances. Records are kept of any monies held by the manager. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new owner and manager have already made improvements to the environment and demonstrate a commitment to continuing this work. EVIDENCE: A tour of the environment was undertaken. The home has a range of communal areas. There is a large conservatory, which has recently been rearranged into smaller, cosy seating areas, a separate lounge area at the front of the home and a separate dining area. There is also a small lounge area close to the entrance of the home, which can Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 20 be used to receive visitors. A bookcase has been placed into this room in case any resident wishes to use it as a reading room. The new acting manager and owner are aware that the environment needs attention and to that end they have employed a maintenance person. Four bedrooms have been decorated since the last inspection and liquid soap and paper towel dispensers have been fitted in all communal bathrooms and toilets. Many of the rooms have been de-cluttered. There are plans being made to cover all of the radiators. The acting manager has checked that all the required maintenance has been carried out. If not, she has made arrangements for these to be done. The home is built on two levels and there are bedrooms on both floors. Some of the bedrooms have en-suite facilities, although most residents have to share communal bathroom facilities. There are bathrooms available on both floors. The present bathrooms are ‘cold’ and unwelcoming and require redecoration. A broken bath panel needs fixing to ensure the safety of residents. Handrails need to be fitted in the en-suite toilets and a sink is required in one of the communal toilets. A strong malodour was noticed in one of the bedrooms. The manager is aware that a new carpet is needed. There are plans to co-ordinate the bedroom furnishings and make them more attractive and homely. Domestic staff work both mornings and afternoons in the home, although it is hard for them to make an impression when much of the home requires redecoration to ‘freshen’ it up. There is a pleasant courtyard area at the back of the home and handrails have been fitted to the front. The manager reported that the owner has instructed her to make a list of all the jobs required. Discussions with the owner demonstrated a commitment to improving the environment. The Environmental Health and Health and Safety Departments have visited the home and any requirements made have been addressed. The manager has completed new fire risk assessments and individual evacuation procedures. The environment was discussed in great detail with the owner and the manager and the owner agreed to develop a maintenance plan, which identifies the work to be carried out and the anticipated timescales. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well-recruited, trained and motivated staff protect the residents. EVIDENCE: There are presently 20 people residing in Alison House. The rota shows the following staffing levels: Morning: manager and three care workers, 1 cook (08:00-17:00) 1 cleaner, 1maintenance person (09:00-14:00). Afternoon/evening: deputy manager and two care workers. Night: two care workers. The new acting manager has introduced new roles and responsibilities for the staff, including the introduction of a key worker system. The staff spoke positively of the changes in the Home and said that they were enjoying their new roles. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 22 One of the senior care staff has been promoted to deputy manager and works closely with the manager. Many of the staff team have worked in Alison House for a number of years, including the new manager and deputy. 50 of the care staff have achieved National Vocational Qualification 2 or above. The training records were not checked during this inspection. However, discussions with the staff and manager indicated that numerous courses have been arranged and attended in the last few months. These include fire safety, Health and Safety, Protection of Vulnerable Adults, dementia, Emergency First Aid and The Safe Handling of Medicines. The manager has obtained a ‘Skills for Care’ induction booklet and a new member of staff is completing this with the support of an experienced care worker as mentor. One of the senior care staff is qualified to train manual handling and the staff have received this training. The senior staff and management undertake training applicable to their senior roles. The manager and owner were asked to check the depth of ‘dementia’ training, particularly as they are hoping to increase the number of people with dementia care needs they can admit into the home. The cook and auxiliary staff have been included in the training. The new acting manager has recruited one member of staff since coming into post. The file for this member of staff was checked during this inspection. The file itself was maintained in an organised and professional manner and contained all of the required elements. Satisfactory checks are carried out prior to employment, including Criminal Records Bureau, Protection of Vulnerable Adults and references. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new management team have made a positive impact on the service provided for the residents. The management arrangements however must be formalised with the Commission for Social Care Inspection. EVIDENCE: Alison House has a new owner and manager. The owner, Mrs Odedra is registered with the Commission for Social Care Inspection. The manager, Mrs Sharon Allen is presently completing her application for registration. She is also undertaking the Registered Managers Award and hopes to be finished by February 2007. Mrs Allen has worked at Alison House Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 24 for many years, latterly as the deputy manager. She demonstrates a strong commitment to the residents and staff. New systems of working have been introduced and action taken to address any previous Commission for Social Care Inspection concerns. These include care records, training, staff responsibilities, recruitment procedures, maintenance issues and Quality Assurance. The staff spoken to during this inspection were enthusiastic about the new management and the changes made. The registered person, Mrs Odedra is required to formally notify the Commission for Social Care Inspection that Mrs Catherine Redman has ceased to be the registered manager of Alison House. The letter must also outline the arrangements made for the running of Alison House in the absence of a registered manager and the plans for registering a manager with the Commission for Social Care Inspection. A letter was sent to Mrs Odedra on 13/10/06 notifying her of this requirement and she was reminded during the inspection. The new acting manager has implemented a Quality Assurance system and has taken steps to ascertain the views of the residents, relatives, staff and professionals. She is planning to collate the answers and draw up an action plan. The new owners use an independent body to audit the home on a monthly basis. Copies of their reports are sent to the owner, manager and the Commission for Social Care Inspection. The residents’ families manage their finances. Records are kept of any monies held by the manager, which include receipts for all transactions and signatures. The manager has started a staff supervision programme. She shares some of this responsibility with the deputy manager and the senior care workers. At the moment supervision takes the form of an observation followed by feedback. It was recommended that the manager also introduce opportunity for staff to sit with a manager and discuss any concerns. Her attention is drawn to National Minimum Standard 36.3. It is recommended that supervision sessions be recorded and signed by the supervisor and supervisee. The owner was reminded that she should supervise the manager. Record keeping has improved. The acting manager has re-organised the paperwork and created better access to information. This includes staff and residents’ records. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 25 The owner and manager agreed to develop an action plan for the environment. It was recommended that the Health and Safety audits be completed in greater depth and include more information. Any identified risks should be carefully assessed. These will help to inform the environmental action plan and set priorities for the work to be done. The deputy manager is now responsible for the Health and Safety in the home. She was reminded to date all risk assessments. The acting manager has completed new fire risk assessments and individual fire evacuations. A random selection of the Health and Safety maintenance records were checked and they provide evidence that regular safeguarding checks take place. The manager has identified that an electrical wiring certificate is required and this has been organised. Requirements made as a result of an Environmental Health inspection have been addressed. Regular fire drills are organised and staff have attended fire safety training. Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 3 3 Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22 (5) Requirement The registered person shall supply a written copy of the complaints procedure to every service user and to any person acting on behalf of a service user if that person so requests. The premises to be used as the care home must be of sound construction and kept in a good state of repair. All parts of the care home must be kept clean and reasonably decorated. 3 OP31 3 39 The registered person is required to formally notify the Commission for Social Care Inspection that Mrs Catherine Redman has ceased to be the registered manager of Alison House. The letter must also outline the arrangements made for the running of Alison House in the absence of a registered manager and the plans for registering a manager with the Commission for Social Care Inspection DS0000067292.V316645.R01.S.doc Timescale for action 10/12/06 2 OP19 23 (b, d) 10/12/06 01/12/06 Alison House Version 5.2 Page 28 Letter sent previously on 13/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that the mobility assessments be expanded to include more information as to how the residents are to be supported. It is recommended that the reason why residents do not use their bedroom door key be justified within the care records, probably within a risk assessment. In order that all relevant parties are aware of the complaints procedure the manager should make sure that it is freely available to all relevant parties. It is also recommended that all concerns and grumbles be recorded as evidence that action is taken to address all issues, no matter how ‘minor’. It is recommended that a maintenance plan be sent to the CSCI to demonstrate the commitment of the owner to meet the environmental requirements. It is recommended that the quality and depth of ‘dementia’ training be assessed, to ensure that it meets the needs of the residents. It is recommended that the manager also introduce opportunity for staff to sit with a manager and discuss any concerns. Her attention is drawn to National Minimum Standard 36.3. It is recommended that supervision sessions be recorded and signed by the supervisor and supervisee. The owner is reminded that she should supervise the manager. 2 OP10 3 OP16 4 OP16 5 OP19 6 OP30 7 OP36 8 OP36 Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 29 9 10 OP38 It is recommended that the Health and Safety audits be completed in greater depth and include more information. It is recommended that the Health and Safety audit inform the environmental action plan and set the priorities for the work to be done. OP38 Alison House DS0000067292.V316645.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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